Edmonton Symptom Assessment Scale Scores Research Articles

Integrating Patient-Reported Outcomes Into Prognostication in Gastroesophageal Cancer: Results of a Population-Based Retrospective Cohort Analysis.

Patient-reported outcomes measures (PROM) are self-reflections of an individual's physical functioning and emotional well-being. The Edmonton Symptom Assessment Scale (ESAS) is a simple and validated PRO tool of 10 common symptoms and a patient-reported functional status (PRFS) measure. The prognostic value of this tool is unknown in patients with gastroesophageal cancer (GEC). In this study, we examined the association between the ESAS score and overall survival (OS) in patients with GEC, the prognostication difference between ESAS and Eastern Cooperative Oncology Group (ECOG), and assessed the correlation between PRFS and the physician-reported ECOG performance status (PS). The study was a retrospective cohort study of 211 patients with GEC with localized (stages I-III) and metastatic disease who completed at least one baseline ESAS prior to treatment. Patients were grouped into 3 cohorts based on ESAS score. OS was assessed using the Kaplan-Meier method, and the concordance index (c-index) was calculated for ESAS and physician-reported ECOG. The agreement between PRFS and physician-ECOG was also assessed. In total, 211 patients were included. The median age was 60.8 years; 90% of patients were ECOG PS 0-1; 38% of patients were stages I-III, while 62% were de novo metastatic patients. Median OS in low, moderate, high symptom burden (SB) patients' cohorts was 19.17 m, 16.39 mm, and 12.68 m, respectively (P < .04). The ability to predict death was similar between physician-ECOG and ESAS (c-index 0.56 and 0.5753, respectively) and PRFS and physician-ECOG (c-index of 0.5615 and 0.5545, respectively). The PS agreement between patients and physicians was 50% with a weighted Kappa of 0.27 (95% CI: 0.17-0.38). Patient's SB seems to carry a prognostic significance. ESAS and physician-reported ECOG exhibit comparable prognostic values. Physicians and patients can frequently have divergent opinions on PS. ESAS takes a patient-centered approach and should be encouraged in practice among patients with GEC as an additional tool for prognostication.

Palliative Care Among Lung Cancer Patients With and Without COPD: A Population-Based Cohort Study.

Lung cancer patients with chronic obstructive pulmonary disease (COPD) may have greater palliative care needs due to poor prognosis and symptom burden. We sought to compare the provision of timely palliative care and symptom burden by COPD status. We performed a retrospective, population-based cohort study of individuals diagnosed with lung cancer in Ontario, Canada (2009-2019) using health administrative databases and cancer registries. The impact of COPD on the probability of receiving palliative care was determined accounting for dying as a competing event, overall and stratified by stage. The provision of palliative care for patients with severe symptoms (Edmonton Symptom Assessment Scale score ≥ 7), location of the first palliative care visit and symptom severity were compared by COPD status. A total of 74,993 patients were included in the study (48% of patients had available symptom data). At the time of lung cancer diagnosis, 50% of patients had COPD. Stage I-III patients with COPD were more likely to receive palliative care (adjusted Hazard Ratio (HR)s: 1.05-1.31) with no difference for stage IV (1.02, 95% CI: 1.00-1.04). Despite having severe symptoms, very few patients with early-stage disease received palliative care (Stage I: COPD-23% vs. no COPD-18%, SMD=0.12). Most patients (84%) reported severe symptoms and COPD worsened symptom burden, especially among early-stage patients. COPD impacts the receipt of palliative care and symptom burden for patients with early-stage lung cancer. Many patients with severe symptoms did not receive palliative care, suggesting unmet needs among this vulnerable population.

Impact of an outpatient palliative care consultation and symptom clusters in terminal patients at a tertiary care center in Pakistan

BackgroundPatients with terminal diseases may benefit physically and psychosocially from an outpatient palliative care visit. Palliative care services are limited in Pakistan. An improved understanding of the symptom clusters present in our population is needed. The first outpatient palliative care center in Karachi, Pakistan, was established at our tertiary care institution. The primary aim of this study was to evaluate the impact of a palliative care outpatient consultation on symptom burden in patients with a terminal diagnosis. The secondary aim was to analyze the symptom clusters present in our population.MethodsPatients with a terminal diagnosis referred to our outpatient palliative department between August 2020-August 2022 were enrolled. The Edmonton Symptom Assessment Scale (ESAS) questionnaire was administered at the initial visit and the first follow-up visit at one month. Change in symptom burden was assessed using a Wilcoxon signed ranks test. A principal component analysis with varimax rotation was performed on the symptoms reported at the initial visit to evaluate symptom clusters. The palliative performance scale (PPS) was used to measure the performance status of palliative care patients.ResultsAmong the 78 patients included in this study, the average age was 59 ± 16.6 years, 52.6% were males, 99% patients had an oncological diagnosis, and the median duration between two visits was 14 (Q1-Q3: (7.0, 21.0) days. The median PPS level was 60% (Q1-Q3: 50–70). Overall, ESAS scores decreased between the two visits (6.0 (2.8, 11.0), p < 0.001) with statistically significant improvement in pain (5.0 vs. 2.5, p < 0.001), loss of appetite (5.0 vs. 4.0, p = 0.004), depression (2.0 vs. 0.0, p < 0.001), and anxiety (1.5 vs. 0.0, p = 0.032). Based on symptoms at the initial visit, 3 clusters were present in our population. Cluster 1 included anxiety, depression, and wellbeing; cluster 2 included nausea, loss of appetite, tiredness, and shortness of breath; and cluster 3 included drowsiness.ConclusionAn outpatient palliative care visit significantly improved symptom burden in patients with a terminal diagnosis. Patients may benefit from further development of outpatient palliative care facilities to improve the quality of life in terminally ill patients.

Retrospective Outcomes of a New Acupuncture Service at a Comprehensive Cancer Center.

Introduction: Among cancer centers, patients' interest in acupuncture is growing, in addition to clinical research in the intervention. Their National Cancer Institute-designated comprehensive cancer center piloted an acupuncture service. Their aim was to assess whether acupuncture impacted patient self-reported symptoms as delivered clinically and discuss their implementation strategy. Methods: Patients undergoing acupuncture at a comprehensive cancer center from June 2019 to March 2020 were asked to complete a modified Edmonton Symptom Assessment Scale (ESAS) before and after each session. The authors evaluated symptom changes after acupuncture in both outpatient and inpatient settings. A change of ≥1 U, on the 0-10 scale, was considered clinically significant. Results: Three hundred and nine outpatient and 394 inpatient acupuncture sessions were provided to patients at the comprehensive cancer center during this period, of which surveys from 186 outpatient (34 patients) and 124 inpatient (57 patients) sessions were available for analysis. The highest pretreatment symptoms reported by outpatients were neuropathy (5.78), pain (5.58), and tiredness (5.59). Outpatients receiving acupuncture reported clinically significant improvements in pain (ESAS score change of -2.97), neuropathy (-2.68), decreased lack of well-being (-2.60), tiredness (-1.85), nausea (-1.83), anxiety (-1.56), activities of daily living issues (-1.32), depression (-1.23), anorexia (-1.19), insomnia (-1.14), and shortness of breath (-1.14). The most severe pretreatment symptoms reported by inpatients were pain (6.90), insomnia (6.16), and constipation (5.44). Inpatients receiving acupuncture reported clinically significant improvements in anxiety (-3.69), nausea (-3.61), insomnia (-3.26), depression (-2.98), pain (-2.77), neuropathy (-2.68), anorexia (-2.20), constipation (-1.95), and diarrhea (-1.26). Conclusion: Both outpatient and inpatient participants in this pilot acupuncture program reported clinically significant improvements in symptoms after a single acupuncture treatment. Some differences between the outpatient and inpatient settings warrant further investigation.

Nurse-guided patient self-treatment in integrative oncology: a randomized controlled trial

Nurses are increasingly becoming involved in integrative oncology (IO) programs. This study examined the additive effect of nurse-provided guidance for self-administered IO therapies on cancer-related fatigue and quality of life (QoL). The study was randomized and controlled, enrolling patients undergoing active oncology treatment with IO interventions for fatigue and other QoL-related outcomes. IO practitioner guidance on self-treatment with manual, relaxation, and/or traditional herbal therapies was provided to patients in both the intervention and control arms. However, patients in the intervention arms also received additional guidance on self-treatment by IO-trained palliative care nurses. All participants were assessed for fatigue and QoL at baseline and at 24-h follow-up, using the Edmonton Symptom Assessment Scale (ESAS) and the Measure Yourself Concerns and Wellbeing (MYCAW) questionnaire tools. Of 353 patients recruited, 187 were randomized to the intervention and 166 to the control group. Both groups had similar demographic and oncology-related characteristics. Patients in the intervention arm reported significantly greater improvement in ESAS scores for fatigue (p = 0.026) and appetite (p = 0.003) when compared to controls. The addition of nurse-provided guidance on self-administration of IO treatments to that provided by IO practitioners further reduced short-term scores for fatigue and improved appetite. The relationship between palliative and IO-supportive cancer care requires further study.

Associations between symptoms with healthcare utilization and death in advanced cancer patients

IntroductionThere is limited data about assessments that are associated with increased utilization of medical services among advanced oncology patients (AOPs). We aimed to identify factors related to healthcare utilization and death in AOP.MethodsAOPs at a comprehensive cancer center were enrolled in a Center for Medicare and Medicaid Innovation program. Participants completed the Edmonton Symptom Assessment Scale (ESAS) and the Functional Assessment of Cancer Therapy–General (FACT-G) scale. We examined factors associated with palliative care (PC), acute care (AC), emergency room (ER), hospital admissions (HA), and death.ResultsIn all, 817 AOPs were included in these analyses with a median age of 69. They were generally female (58.7%), white (61.4%), stage IV (51.6%), and represented common cancers (31.5% GI, 25.2% thoracic, 14.3% gynecologic). ESAS pain, anxiety, and total score were related to more PC visits (B=0.31, 95% CI [0.21, 0.40], p<0.001; B=0.24 [0.12, 0.36], p<0.001; and B=0.038 [0.02, 0.06], p=0.001, respectively). Total FACT-G score and physical subscale were related to total PC visits (B=−0.021 [−0.037, −0.006], p=0.008 and B=−0.181 [−0.246, −0.117], p<0.001, respectively). Lower FACT-G social subscale scores were related to more ER visits (B=−0.03 [−0.53, −0.004], p=0.024), while increased tiredness was associated with fewer AC visits (B=−0.039 [−0.073, −0.006], p=0.023). Higher total ESAS scores were related to death within 30 days (OR=0.87 [0.76, 0.98], p=0.027).ConclusionsThe ESAS and FACT-G assessments were linked to PC and AC visits and death. These assessments may be useful for identifying AOPs that would benefit from routine PC.

Integrating patient-reported-outcomes into prognostication in gastroesophageal cancer: Results of a population-based retrospective cohort analysis.

320 Background: Patient reported outcomes (PRO) measures are accurate self-reflections of an individual’s physical functioning and emotional well-being. The prognostic value is unknown in gastroesophageal (GE) cancer patients (pts). The Edmonton Symptom Assessment Scale (ESAS) is a simple and validated 10-item PRO tool which uses a 0 to 10 rating of ten common symptoms (total rating 0-100). In this study, we examined the association between the ESAS score and overall survival (OS) in pts with localized and metastatic GE adenocarcinoma (GEA). Methods: This study is based on the retrospective cohort database of pts with localized (stage I-III) and metastatic GEA. We included pts who were diagnosed with GEA between 2011 and 2021 and completed at least 1 baseline ESAS prior to the treatment. Pts were grouped into 3 cohorts based as follows: High symptom burden (SB) ESAS score ≥ 26, Moderate SB (11-25) or low SB (0-10). OS was defined as time from the first visit date to death. OS was assessed using the Kaplan-Meier method and significance was set at 2-sided P &lt; 0.05. Univariate statistical analyses were used to examine the relationships between OS and multiple variables in the presentation. Results: 233 pts met the inclusion criteria: median age was 60.8y [51.4, 69.4]; 58% of pts were ECOG PS 1; 81% were non-Asian and 18.9% Asian; 67.4% of pts were male and 32.6% female. In terms of tumor location, gastric represented 47.2% of pts, GEJ 40.8% and esophageal 12.0% primaries; 43.7% pts were stage I-III, while 56.3% were de-novo metastatic pts. Median OS in Low, Mod, High SB pts cohorts were 22.7m, 17.6mm, &amp; 14.6m, respectively (p &lt; 0.036). Although worse OS and worse ESAS levels were not statistically significant in the localized pts (p, 505) and metastatic subgroup (p 0,092), there was a numerical tendency, especially in the metastatic pts. In the univariate analysis, there was a significant association between OS and high-symptom burden (Hazard ratio [HR] = 1.64 (95% CI, 1.12-2.38; p = 0.0104), ECOG ≥2 (HR= 2.79 (95% CI, 1.62-4.79; p = 0.0002) and metastatic pts (HR= 3.50 (95% CI, 2.51-4.86, p&lt;0.0001). Conclusions: Higher SB based on ESAS was associated with poorer OS among GEA pts. ESAS is a reliable tool that carries a prognostic significance that could be used in practice.[Table: see text]

Patient-Reported Outcomes in Cancer Patients with HIV.

Elevated cancer-specific mortality in PWH has been demonstrated for non-AIDS-defining malignancies. However, additional clinical endpoints of interest, including patient-reported outcomes (PROs), have not been systematically examined in PWH and cancer. We evaluated differences in patient-reported symptomology between cancer patients with versus without HIV using data from 12,529 patients at the Moffitt Cancer Center, including 55 with HIV. The symptoms were assessed using the Edmonton Symptom Assessment Scale (ESAS), which asks patients to rank 12 symptoms on a scale of 1−10, with scores ≥7 considered severe. The responses across all questions were summed to create a composite score. Vital status through t July 2021 was determined through linkage to the electronic health record. PWH reported a higher composite ESAS score on average (44.4) compared to HIV-uninfected cancer patients (30.7, p-value < 0.01). In zero-inflated negative binomial regression models adjusted for cancer site, sex, and race, the composite ESAS scores and the count of severe symptoms were 1.41 times (95% CI: 1.13−1.77) and 1.45 times (95% CI: 1.09−1.93) higher, respectively, in cancer patients with HIV. Among PWH, higher ESAS scores were associated with mortality (p-value = 0.02). This is the first demonstration of uniquely poor PROs in PWH and cancer and suggests that patient symptom monitoring to improve clinical endpoints deserves further study.

Screening for supportive care services in the neuro-oncology patient: A quality improvement project.

355 Background: On average, 80 to 85% of patients diagnosed with brain tumors qualify for supportive care under the American Society of Clinical Oncology (ASCO) recommendations. The National Comprehensive Cancer Network (NCCN) recommends routine screening, yet in our experience only 39% are screened in-clinic and 8.7% qualifying are referred. Evidence within the literature suggests consistent patient symptom screening and reflexive supportive care referral leads to improved quality of life and treatment plan adherence, and reduced symptom burden, healthcare costs, and less aggressive end-of-life care. This QI/IS project sought to improve quality of life through increased symptom screening via the Edmonton Symptom Assessment Scale (ESAS) and initiation of supportive care referral in Neuro-Oncology patients. Methods: Institutional Review Board (IRB) appraisal deemed this project non-regulatory research. A retrospective chart review assessed pre-implementation consistency of patients screened using the ESAS tool, the number indicating symptom burden and supportive care qualification, and if referral was placed. The Plan-Do-Study-Act (PDSA) Framework guided implementation and process evaluation. Interventions focused on improving ESAS use to identify patients who would benefit from supportive services and decreasing barriers to supportive care such as supportive care misinformation, screening burden, and documentation. From October 2021 to March 2022, data collection included the patient demographics ethnicity, age, diagnosis, and encounter date, as well as patient ESAS scores and supportive care referrals placed. Results: Over a five-month implementation period, 357 ESAS symptom burden tools were completed and documented out of 378 patient encounters in the neuro-oncology outpatient clinic. Clinic ESAS completion rates increased from 39.3% to 94.4%. Symptom burden qualifying for supportive care referral improved in 18% (N = 66), down from 31.2% (N = 102) of patients. Of patients qualifying, referrals increased from 4.9% (N = 5) to 10.7% (N = 7). Conclusions: Consistent use of a patient screening process led to an increase in the number of identified patients with significant symptom burden and referral for supportive care services, meeting all project goals. Initially, qualified rates increased with improved screening processes and clinic education, then steadily decreased to indicate better symptom control. This suggests a process capable of meeting the screening needs of oncology patients and minimal resource needs to maintain long-term sustainability. Future projects aimed at supportive care access and resource availability are recommended.[Table: see text]

Patient reported outcomes in advanced penile cancer.

Patient reports of their symptom burden (i.e., patient-reported outcomes or PROs) have been shown to direct clinicians' ability to personalize care and improve outcomes. A disciplined assessment of PRO in the population of patients with advanced penile cancer (PeCa) has not previously been undertaken. Our center leveraged a significant cadre of patients with PeCa and a significant experience with a well-established PRO: the Edmonton Symptom Assessment Scale (ESAS). After IRB approval, we screened ESAS surveys of 14,781 patients completed between February 2017 and February 2021; these were collected in the Supportive Care and Radiation Oncology clinics. Of these, those with PeCa were divided into 3 cohorts: (A) Those after any partial penectomy procedure without lymph node dissection (LND); (B) Those after partial penectomy procedure with LND; and (C) Those after total penectomy and LND. Patients with recurrent disease were analyzed separately (D). ESAS scores were collated and compared both by individual symptom and cumulatively. Twenty-two PeCa patients completed 122 ESAS surveys in this time and are included in this analysis: a median of 4 ESAS surveys (mean = 5, range = 1-19) were completed by each patient. The symptom with the highest median ESAS score was Tiredness (3.00). Patients with recurrent disease had the highest cumulative symptom score (median score = 30). Patients after total penectomy with LND had a higher cumulative symptom score (14.4) than those with partial penectomy and LND (7.9). Patients with partial penectomy without LND had a cumulative score of 22. PROs provide an insight into the morbidity of therapies for advanced PeCa, and the most symptoms are reported by patients with recurrent disease.

Edmonton Symptom Assessment Scale may reduce medical visits in patients undergoing chemotherapy for breast cancer.

BACKGROUNDAdjuvant chemotherapy is recommended in high-risk breast cancer. However, no universally accepted guidelines exist on pre-chemotherapy assessment. In particular, the number and frequency of medical visits vary according to each institution’s policy. We hypothesised that the Edmonton Symptom Assessment Scale (ESAS) may have a favourable impact on the pre-treatment assessment in candidates for adjuvant chemotherapy.AIMTo investigate whether the ESAS can be used to safely reduce the number of medical visits in women with breast cancer undergoing adjuvant chemotherapy.METHODSIn a retrospectively prospective matched-pair analysis, 100 patients who completed the ESAS questionnaire before administration of adjuvant chemotherapy (ESAS Group) were compared with 100 patients who underwent chemotherapy according to the traditional modality, without ESAS (no-ESAS Group). Patients of the ESAS Group received additional visits before treatment if their ESAS score was > 3. The primary endpoint was the total number of medical visits during the entire duration of the chemotherapy period. The secondary endpoints were the occurrence of severe complications (grade 3-4) and the number of unplanned visits during the chemotherapy period.RESULTSThe study variables did not statistically differ between patients of the ESAS Group and no-ESAS Group (age P = 0.880; breast cancer stage P = 0.56; cancer histology P = 0.415; tumour size P = 0.258; lymph node status P = 0.883; immunohistochemical classification P = 0.754; type of surgery P = 0.157), except for premenopausal status (P = 0.015). The study variables did not statistically differ between patients of the ESAS Group and no-ESAS Group regarding age, cancer stage, histology, tumour size, lymph node status, immunohistochemical classification, and type of surgery. Unplanned visits during the entire duration of chemotherapy were 8 in the ESAS Group and 18 in the no-ESAS Group visits (P = 0.035). Grade 3-4 toxicity did not differ between the study groups (P = 0.652). Forty-eight patients of the ESAS Group received additional visits due to an ESAS score > 3. The mean number of medical visits was 4.38 ± 0.51 in the ESAS Group and 16.18 ± 1.82 in the no-ESAS group (P < 0.001). With multivariate analysis, women of the ESAS group were more likely to undergo additional visits for an ESAS score > 3 if they were aged 60 or older, received a mastectomy, or had tumour stage II/III.CONCLUSIONThe ESAS score may safely reduce the number of medical visits in candidates for adjuvant chemotherapy for early breast cancer. Our results suggest that the ESAS score may be used for selecting a group of breast cancer patients for whom it is safe to reduce the number of medical visits in the setting of adjuvant chemotherapy. This may translate into several advantages, such as a more rational utilization of human resources and a possible reduction of coronavirus pandemic infection risk in oncologic patients.

Assessment and Management Tools for Advancing Disease.

As the population of the United States has aged, the number of home care patients with multiple chronic diseases has also increased. A review of the literature suggested that layering palliative care principles on traditional home healthcare could improve outcomes for patients with advancing disease. The purpose of this quality improvement project was to educate home care staff on the use of assessment and management tools to identify symptoms and provide symptom control, prevent unnecessary hospitalizations, and reduce healthcare costs in patients with advancing disease. This project took place at eight offices of a national home care agency in Kentucky and Indiana. Nurses, social workers, and therapists attended mandatory education sessions over 5 months on integrating palliative care principles into care planning for home care patients and using the Edmonton Symptom Assessment Scale (ESAS) and state-specific end-of-life planning tools. Symptoms were tracked and managed. A paired-samples t-test was used to analyze ESAS scores. Hospitalization and rehospitalization rates and costs were compared and benchmarked. Some symptoms worsened from beginning to end of the episode of care, suggesting a need for additional staff training about symptom management. The wide range of symptoms and symptom worsening suggest the need for individualized care, possibly extended home healthcare, and the inclusion of a more formal palliative care course for staff on symptom management.

Daily symptom monitoring commonly leads to treatment modification in older adults receiving treatment for metastatic prostate cancer (mPC).

82 Background: Treatment options for older adults with mPC expanded significantly in recent years but commonly include chemotherapy with Docetaxel (Chemo), androgen receptor-axis-targeted therapies (ARAT), and Radium-223 (Ra-223). Symptom burden associated with Chemo, ARAT, and Ra-223 is frequently observed and often leads to treatment modification, especially in older men. The objective of this study is to explore how often, and which moderate to severe symptoms during treatment for mPC and triggered follow-up, lead to treatment delay and/or dose reduction. Methods: Men aged 65+ with mPC starting standard dose (n=24) or reduced dose (n=1) Chemo, standard dose (n=41) or reduced dose (n=1) ARATs, or Ra223 (n=12) from two tertiary cancer centres in Toronto, Canada, were enrolled in a prospective cohort study. Participants self-reported symptoms daily using the Edmonton Symptom Assessment Scale (ESAS) for 3-4 weeks either through a web-based interface or phone calls. ESAS scores of &gt;4 were followed by ‘triggered’ detailed questionnaires. The oncology care team was informed of reportable events based on scores of triggered questionnaires and patients were advised to call their care team. Clinical and treatment data were abstracted from electronic patient records and descriptive analysis was used. Results: 52/79 participants (66%) reported 345 moderate to severe symptoms that merited triggered questionnaires (table) with an adherence of 83%. Tiredness (n=74), appetite (n=49), insomnia (n=49), and pain (n=48) were the most frequently reported symptoms. 28 patients reported high scores on triggered questionnaires that led to informing the oncology care team and 79% of these patients were contacted by the care team, or an appointment with the Most Responsible Physician was scheduled. Moderate to severe symptom reporting resulted in treatment modification for 9 patients, Chemo (n=5), ARAT (n=3), and Ra-223 (n=1). Conclusions: Daily monitoring identified clinically relevant symptoms and actionable concerns. Informing care teams of reportable adverse events resulted in contacting patients and ultimately in treatment modification in a considerable number of patients. [Table: see text]

Longitudinal patient-reported outcomes and survival among early-stage non-small cell lung cancer patients receiving stereotactic body radiotherapy

Background and purposeThe study objective was to determine whether longitudinal changes in patient-reported outcomes (PROs) were associated with survival among early-stage, non-small cell lung cancer (NSCLC) patients undergoing stereotactic body radiation therapy (SBRT). Materials and methodsData were obtained from January 2015 through March 2020. We ran a joint probability model to assess the relationship between time-to-death, and longitudinal PRO measurements. PROs were measured through the Edmonton Symptom Assessment Scale (ESAS). We controlled for other covariates likely to affect symptom burden and survival including stage, tumor diameter, comorbidities, gender, race/ethnicity, relationship status, age, and smoking status. ResultsThe sample included 510 early-stage NSCLC patients undergoing SBRT. The median age was 73.8 (range: 46.3–94.6). The survival component of the joint model demonstrates that longitudinal changes in ESAS scores are significantly associated with worse survival (HR: 1.04; 95% CI: 1.02–1.05). This finding suggests a one-unit increase in ESAS score increased probability of death by 4%. Other factors significantly associated with worse survival included older age (HR: 1.04; 95% CI: 1.03–1.05), larger tumor diameter (HR: 1.21; 95% CI: 1.01–1.46), male gender (HR: 1.87; 95% CI: 1.36–2.57), and current smoking status (HR: 2.39; 95% CI: 1.25–4.56). ConclusionPROs are increasingly being collected as a part of routine care delivery to improve symptom management. Healthcare systems can integrate these data with other real-world data to predict patient outcomes, such as survival. Capturing longitudinal PROs—in addition to PROs at diagnosis—may add prognostic value for estimating survival among early-stage NSCLC patients undergoing SBRT.

Sleep disturbance in cancer patients referred to an ambulatory integrative oncology consultation.

Sleep disturbance (SD) is highly prevalent in oncology and negatively affects quality of life and mortality. Evidence supports the use of integrative oncology (IO) practices to treat SD, but there is limited published data on the characteristics of SD and factors associated with SD in IO. We determined the prevalence, severity, and factors associated with SD among cancer patients seen in an ambulatory IO consultation. Patients with cancer referred for initial outpatient IO consultation in 2017 were eligible. Patient demographics, clinical characteristics, and patient-reported outcomes (Edmonton Symptom Assessment Scale (ESAS), Measure Yourself Concerns and Wellbeing (MYCaW), PROMIS-10) were retrospectively reviewed. One thousand five hundred twenty patients were included in the analysis. The majority (70%) were women with breast cancer (42%). Nine hundred seventy-one (64%) patients reported significant SD with ESAS Sleep ≥ 4, yet only 11% expressed poor sleep as their primary or secondary concern for the IO consultation. The median SD (IQR) was 5 (3,7). ESAS scores for fatigue (adjusted OR 1.16; CI 1.07-1.26, p < 0.001), pain (adjusted OR 1.07; CI 1.00-1.15, p < 0.05), hot flashes (adjusted OR 1.14; CI 1.07-1.22, p < 0.001), well-being (adjusted OR 1.33; CI 1.22-1.46, p < 0.001), and psychological distress score (anxiety and depression) (adjusted OR 1.16; CI 1.01-1.11, p < 0.01) were independently associated with SD in multivariate analysis. Acupuncture was the most frequent intervention prescribed, 175 (35%). Other modalities included oncology massage (15%), health psychology (5%), and meditation (1%). Although 64% of patients seeking IO consultation reported clinically significant SD, only 11% were seeking integrative approaches for managing SD. ESAS fatigue, hot flashes, well-being, and psychological symptoms were significantly associated with SD.

Myelodysplastic Syndromes: Have You Seen Your Patient Beyond His Hemoglobin?

Background: Palliative care (PC) is a patient-centered care model that aims to relief suffering by establishing a plan of care that integrates physical, psychosocial, cultural, familial and spiritual issues during the course of disease's evolution. Thus, PC applies not only to patients who face a diagnosis beyond the possibility of cure, but to all those who experience significant symptoms throughout the course of the disease. Myelodysplastic syndromes (MDS) are a heterogeneous group of myeloid neoplasms characterized by cytopenias and an elevated risk of developing acute leukemia. As MDS display a wide genetic heterogeneity, patients have a variable clinical presentation, ranging from asymptomatic patients to individuals with severe cytopenias and high-risk disease. MDS are more prevalent in the elderly population, which usually experience several morbidities; thus, MDS frequently lead to notable symptoms and deterioration of quality-of-life, making most of them eligible to PC in addition to standard hematologic care. In spite of that, previous studies demonstrated that patients with hematologic malignancies appear to have restricted access to PC services and receive more aggressive therapies at the end of life.Aims: To evaluate eligibility criteria for PC in a cohort of MDS patients and correlate with clinical and laboratory data.Methods: Clinical and demographic data of MDS patients were collected through interviews using a standardized questionnaire: time from diagnosis, number of morbidities, need for seeking the emergency during the last 12mo, delirium events, wounds, dysphagia, recurrent falls, adverse events to medication, quality of communication with the medical team, fears regarding the disease and its complications, religious support, age, gender, monthly household income and level of schooling. Specific PC scores were also applied: Edmonton Symptom Assessment Scale (ESAS) and Palliative Performance Scale (PPS). Clinical and laboratory data were collected: hemoglobin (Hb), platelet and neutrophil counts, Revised International Prognostic Scoring System (IPSS-R) and transfusion burden. Statistical univariate and multivariate analysis were performed. P value <.05 was considered statistically significant. This research was approved by the Institutional and National Review Board; written informed consent was obtained from all subjects.Results:Thirty-six patients were evaluated: median age 68y (21-90), sex 16F/20M. According to ESAS, tiredness and anxiety were the most relevant symptoms in MDS patients [median (min-max)]: pain 0 (0-10), tiredness 4.5 (0-10), drowsiness 1.5 (0-10), nausea 0 (0-7), lack of appetite 0 (0-10), shortness of breath 0 (0-10), depression 0 (0-10), anxiety 3.5 (0-10), best wellbeing 2.5 (0-8). Younger patients (<60y, n=10) had a worse ESAS for best wellbeing (5 (2-8)) when compared to older individuals (≥60y, n=26): (2 (0-7)), p=.007, and tended to have worse ESAS scores for tiredness: 8.5 (0-10) vs 3.5 (0-10), p=.56. Importantly, ESAS for tiredness was not correlated to Hb levels, the number of red blood cell transfusions nor with IPSS-R (all p>.05). ESAS for drowsiness was significantly higher in patients with two (5 (0-10)) and ≥three morbidities (3 (0-8) vs those with only one morbidity (0 (0-10)): p=.01 and p=.03, respectively. ESAS for best wellbeing was better in individuals with higher household income 0 (0-0) vs patients with lower financial resources 3 (0-7), p=.04). PPS median was 90% (60-100%) and negatively correlated with transfusion burden (r=0.407, p=.01) and with the need for seeking the emergency in the past 12mo (r=-0.332, p=.04). Finally, despite facing a potential life-threatening disease, 94.4% of the patients reported that their doctors had never talked to them about aspects related to end-of-life care. Conversely, 75% of them reported fears and doubts regarding this phase.Conclusions: In our casuistic of MDS patients, tiredness was the most important symptom observed. Surprisingly, it was not correlated with Hb levels and transfusion burden, suggesting that Hb levels alone should not be used to justify symptoms. The number of morbidities and lower household income also impacted ESAS scores. Finally, a great part of the patients revealed miscommunication with their hematologists regarding end-of-life planning. Our data indicate that MDS patients might benefit from a PC multidisciplinary team approach. DisclosuresCosta: Novartis: Consultancy.

Comparison of Depressive Symptom Outcomes in Hospitalized Adult Cancer Patients Receiving Music Therapy or Massage Therapy

ContextDepressive symptoms are prevalent and associated with greater healthcare utilization among hospitalized adults with cancer. Music therapy and massage therapy are available at many National Cancer Institute (NCI)-Designated Cancer Centers and recommended by the American Society of Clinical Oncology for depressive symptoms, but a paucity of studies have compared these two therapies. ObjectivesWe conducted a retrospective, multi-method program evaluation of single, first-time music therapy and massage therapy sessions delivered to hospitalized adults with cancer. MethodsThe study was conducted at an NCI-Designated Comprehensive Cancer Center between February 2018 and October 2019. We assessed depressive symptoms with the Edmonton Symptom Assessment Scale (ESAS) depression item. We also invited patients to provide free-text comments describing their treatment experience. ResultsAmong 1764 patients (61.2% women, 72.7% white), 350 received music therapy and 1414 received massage therapy; music therapy was associated with a 0.4 point greater reduction (95% 0.3 to 0.6, P < 0.001) in the ESAS depression score relative to massage therapy. When analyses were restricted to the 452 (25.6%) patients with moderate-to-severe depressive symptoms (ESAS score ≥ 4), music therapy was associated with a 1.2 point greater reduction (95% CI 0.7 to 1.7, P < 0.001) relative to massage therapy, a clinically meaningful difference. In free-text comments, music therapy was described as energizing, uplifting, and evocative, whereas massage therapy was described as calming and relaxing. ConclusionAmong hospitalized adult cancer patients, both music therapy and massage therapy were associated with reduced depressive symptoms, but music therapy was associated with a greater reduction than massage therapy.

Symptom Burden Is Associated with Increased Emergency Department Utilization among Patients with Cirrhosis.

Background: Patients with cirrhosis have significant morbidity and mortality, as well as substantial symptom burden. Objective: We investigated the relationship between symptom burden and inpatient health care utilization among patients with cirrhosis. Methods: Adult patients with cirrhosis being evaluated for or awaiting liver transplantation at an academic institution in the United States completed the Edmonton Symptom Assessment Scale (ESAS), a validated symptom evaluation tool with total scores ranging from 0 to 90. The outcomes of interest were emergency department (ED) visits, nonelective hospitalizations, hospital days, intensive care unit (ICU) admissions, and 30-day readmissions within 6 months. Adjusted incidence rate ratios (IRRs) were used to examine the relationship between ESAS scores and outcomes. Results: Of 233 patients (43% female, median age 61), the median total ESAS score was 16 (interquartile range 6-30). Higher total scores on the ESAS were associated with increased ED visits, hospitalizations, hospital days, and ICU days (all p < 0.04). After adjusting for age, gender, and Model for End-Stage Liver Disease-sodium, ESAS total score remained an independent predictor of ED visits (IRR 1.05, confidence interval [95% CI] 1.00-1.10, p = 0.03). Multivariate ESAS subscale analyses revealed that the physical symptom score was associated with ED visits (IRR 1.09, 95% CI 1.02-1.16, p = 0.01), but the psychological symptom score was not (IRR 1.03, 95% CI 1.00-1.08, p = 0.15). Conclusions: Patient-reported symptoms, particularly physical symptoms, are independently associated with ED visits among patients with cirrhosis being considered for liver transplantation. Further research is needed to examine whether addressing symptoms more aggressively, such as with palliative care co-management, could decrease ED utilization in this population.

Impact of a combined integrative oncology and palliative care program on quality of life of patients with advanced cancer.

Many oncology centers provide integrative oncology (IO) care, many within palliative care settings. The primary study objective was to examine the impact of IO-palliative patient-tailored program on quality of life (QoL) among patients with advanced cancer. In this pragmatic prospective controlled study, patients with advanced cancer undergoing chemotherapy/palliative care were referred by their oncology healthcare providers to an integrative physician (IP) consultation and weekly IO treatments. Patients with high adherence to integrative care (AIC; ≥ 4 IO sessions/6weeks) were compared with moderate (2-3 sessions) or low AIC patients (regarded as control group). Outcomes were assessed at 6- and 12-week follow-up with Edmonton Symptom Assessment Scale (ESAS) and EORTC QLQ-C30 (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire) tools. Change in QoL scores (ESAS fatigue in particular) was considered a primary study outcome. Of 225 eligible patients, 153 underwent baseline and 6-week optimal assessment (high AIC, 100; moderate AIC, 22; low AIC, 31). High AIC patients reported greater improvement on ESAS scores for fatigue (vs. low-moderate AIC, P < 0.001), depression (vs. moderate AIC, P = 0.01) at 6 weeks, and sleep (P = 0.007) at 12weeks. High AIC patients had significantly improved EORTC global health status/QoL at 6weeks (vs. moderate-low AIC, P = 0.01), cognitive functioning (vs. moderate AIC, P = 0.043), and social functioning (vs. moderate AIC, P = 0.032). High AIC patients had lower rates of hospitalizations at 12weeks (19% vs. 35% in low AIC, P = 0.02; 44% in moderate AIC, P = 0.003), hospitalization days (vs. low AIC, P = 0.003), and opioid use (vs. low AIC, P < 0.001). High adherence to integrative care was associated with a significant effect on fatigue, depression, global QoL at 6weeks, and need for hospitalizations at 12weeks.

Symptom Burden Is Associated with Increased Emergency Department Utilization Among Patients with Cirrhosis (SCI921)

1.Describe the healthcare utilization of patients with cirrhosis.2.Interpret the association between symptom burden and health care utilization among patients with cirrhosis.3.Consider how palliative care co-management could help curb emergency department utilization in patients with cirrhosis. Patients with end-stage liver disease have significant morbidity and mortality, as well as substantial health care utilization. Despite this, few are referred to palliative care. How symptom burden impacts health care utilization in this population is unknown. To investigate the association of symptom burden with health care utilization among patients with cirrhosis. This prospective observational cohort study enrolled patients with cirrhosis undergoing outpatient liver transplantation evaluation from 7/1/19-9/30/19. Patients completed the Edmonton Symptom Assessment Scale (ESAS), a validated tool with total scores ranging 0-90 and higher scores indicating higher symptom burden. During 6 months of follow-up, emergency department (ED) visits, non-elective hospitalizations, total hospital days, intensive care unit (ICU) admissions, and 30-day readmissions were abstracted from the medical record. Of 233 patients (43% female, median age 61), the median total ESAS score was 16 (IQR 6-30). Over 6 months of follow-up, the mean (SD) total ED visits was 0.4 (1.2). Patients had mean (SD) 0.7 (1.4) hospitalizations, resulting in 3.3 (8.0) total hospital days and 0.4 (1.7) total ICU days. Hospital readmission rate within 30 days was 11%. Higher scores on the ESAS (per 5-point increase) were associated with increased ED visits (IRR=1.08, 95% CI 1.02-1.15, p=0.005), hospitalizations (IRR=1.08, 95% CI 1.02-1.13, p=0.01), total hospital days (IRR=1.06, 95% CI 1.01-1.10, p=0.01), total ICU days (IRR=1.08, 95% CI 1.00-1.16, p=0.04), and there was a trend towards increased 30-day readmissions (OR=1.02, 95% CI 1.00-1.04, p=0.06). After adjusting for age, sex, and MELDNa, ESAS remained an independent predictor of ED visits (IRR=1.07, 95% CI 1.01-1.13, p=0.03). Patient-reported symptoms are independently associated with ED visits, but not hospitalizations and ICU admissions, among patients with cirrhosis.